Dry Needling Consent Form

Dry Needling Consent Form
Holt: 2380 Cedar St Ste 203 Holt MI 48842

Frandor: 3315 E Michigan Ave Ste 6 Lansing MI 48912

Grand Ledge: 615 S Clinton St Grand Ledge MI 48837

Howell: 751 S Latson Rd Ste C Howell MI 48843

P: 517-709-4677 F: 517-798-5667

Dry needling involves inserting a tiny monofilament needle in a muscle or muscles in order to release tension in muscles and especially in trigger points. This can help resolve pain and muscle tension, and will promote healing. This is note traditional Chinese acupuncture, but is instead a medical treatment that relies on a medical diagnosis to be effective. Dry needling is a valuable and effective treatment for pain of musculoskeletal pain. Like any treatment, there are possible complications. While complications are rare, they are real and must be considered prior to giving consent for treatment.

PRECAUTIONS/RISKS: The most serious risk with dry needling near the thorax is puncture of the lung called pnuemo-thorax. If this were to happen, it may likely require a chest x-ray and no further treatment. The symptoms are shortness of breath and may last from days to several weeks. A more severe puncture can require hospitalization and re-inflation of the lung. This is a rare complication, and in skilled hands it should not be a major concern. Other risks include injury to a blood vessel causing bruise, infection and or nerve injury. Bruising is a common occurrence and should not be a concern.

Patient Consent: I understand that no guarantee or assurance has been made as to the results of this procedure and that it may not cure my condition. My therapist has also discussed with me the probability of success of this procedure, as well as the probability of serious side effects. Multiple treatment sessions may be required and or needed, this consent will cover this treatment as well as consecutive treatments by this facility. I have read and fully understand this consent form and understand that I should not sign this form until all item, including my questions have been explained or answered to my satisfaction. With my signature, I hereby consent to the performance of this procedure. I also consent to any measures necessary to correct complications which may result.

Please answer the following:
Have you ever fainted or experienced a seizure?*
Do you have a pacemaker or any other electrical implants?*
Are you currently taking anticoagulants (ex. blood thinners)?*
Are you currently taking antibiotics for an infection?*
Do you have a damaged heart valve, metal, or other risk of infection?*
Are you pregnant?*
Do you suffer from metal allergies?*
Are you a diabetic or do you suffer from impaired wound healing?*
Do you have hepatitis B, C, HIV or any other infectious disease?*
Do not sign unless you have read and thoroughly understand this form. You have the right to withdraw consent for this procedure at time before it is performed.
Signature*

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Patient Name (printed)*
Relationship to patient (if other than patient)
Date*

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